Original Article

Study on high risk factors of breast cancer amongst working women from Delhi, India

¹Anita Khokhar

• ¹Dept. of Community Medicine, Room No.617 V.M.M.C. & Safdarjung Hospital Delhi, India

• Friday, June 21, 2013
• Friday, July 26, 2013
• Friday, July 26, 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0)which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

Abstract

Introduction

Breast cancer is on the rise in urban population of India. It is imperative to identify the high risk factors of this disease and screening practices of the women.

Study design

Descriptive, cross- sectional

Materials and methods

The community based study was conducted in all the women more than 20 years of age working at 10 different offices at Delhi, India. All those women who attended the breast cancer early detection programme conducted at their offices during 2012-13 were included in this study. Self administered questionnaire were used to collect the necessary data. Data was entered in Microsoft Excel and SPSS version 21 was used to analyse the results

Results

The present study was conducted in a total of 721 women from 10 offices of Delhi where only 12.2% had reached menarche before 12 years of age. From amongst the married women 24(4.3%) delivered their first child after 30 years of age. 96.7% of the married women with children had breast fed their new-born. History of oral contraceptive use was present in 301(41.7%) of the women. Only 48(6.6%) of the women had ever taken HRT. Red meat was not consumed by 452(62.6%) of the women and only 28/721(3.9%) consumed red meat 3 times or more in a week .Physical exercise of 30 minutes 5times or more per week was undertaken by only 49(6.8%).321(44.5%) of the women were overweight and 274(38%) obese. 19(2.6%) of the women had themselves undergone treatment for breast cancer. Main perceived reason for cancer of the breast cited by women was diet (adulteration/pesticides) 487(67.5%) followed by family history of breast cancer by 459(63.7%). Only 32(4.4%) had ever examined their breasts. None had gone for a clinical breast examination as a screening method and only five (0.7%) had gone for a screening mammogram from their side.

Conclusion

Overweight and lack of physical activity are widely prevalent in women. Also perceptions about the causes of breast cancer and practice of screening are poor. This calls for efforts to make them aware about the disease and the screening modalities.

Key words

Breast cancer, high risk factors, working women, screening.

Introduction

Breast cancer is the commonest cancer among women in urban registries of Delhi, Mumbai, Ahmedabad, Kolkata, and Trivandrum where it constitutes >>30% of all cancers in females[1].The incidence of this disease has been consistently increasing, and it is estimated it has risen by 50% between 1965 and 1985 [2].The rise in incidence of 0.5-2% per annum has been seen across all regions of India and in all age groups but more so in the younger age groups (<45 years) [3].Most of this increase has been associated with greater urbanization and changing life styles. The present study was planned with the aim to find out the high risk factors for breast cancer amongst working women from Delhi.

Material and methods

This community based study was conducted amongst women employees of 10 offices of Delhi. Women more than 20 years of age working in various public sector offices were included in this study. This study was a part of training workshop on early detection of breast cancer organized for the employees. Administrative approval was taken from the administrative heads of all the offices before the conduct of the workshop. Before the start of the workshop necessary information was collected with the help of predesigned, structured questionnaire which was self-administered. Questionnaire had sections pertaining to high risk factors of breast cancer, screening for breast cancer, perceived reasons of breast cancer, its symptoms and any concerns related to breasts. They were asked to mention their weight and height also.Body mass Index was calculated and criteria for obesity issued by Ministry of Health, Government of India [4].A total of 721 women who volunteered were included in the study. Each of the workshop session had attendance of 50 to 75 women. The study was conducted in the year 2012-13.The data was entered in Microsoft Excel and analyzes using SPSS software version 21.

Result

721 women from 10 offices of Delhi. 88(12.2%) had reached menarche before 12 years of age. Only 37(5.1%) of the women had married after 30 years of age. From amongst a total of 553 married women 24(4.3%) delivered their first child after 30 years of age. Only 4(0.7%) of the eligible women had never borne a child. Most of the married women with children, 531/549(96.7%), had breast fed their new-born. Average duration of breast feeding for 216(39.3%) was more than 6 months. 104(14.4%) had history of abortion. History of oral contraceptive use was present in 301(41.7%) of the women. Only 48(6.6%) of the women had ever taken HRT. Eight (1.1%) of the women reached menopause after 51 years of age. Red meat was not consumed by 452(62.6%) of the women and only 28/721(3.9%) consumed red meat 3 times or more in a week. Physical exercise of 30 minutes 5times or more per week was undertaken by only 49(6.8%).321(44.5%) of the women were overweight and 274(38%) obese. (Table 1).

Tables1: Distribution of the participants according to prevalence of high risk factors of breast cancer (N=721).

Age at menarche (years)	n	%
10-12	88	12.2
13-15	599	83.1
16-18	34	4.7
Age at marriage (years)
Unmarried	168	23.3
Less than 20	27	3.7
20-25	354	49.1
26-30	135	18.7
More than 30	37	5.1
Age at first delivery n=553
20-25	251	45.4
26-30	274	49.5
More than 30	24	4.3
No children	04	0.7
Number of children=553
None	04	0.7
1	135	24.4
2	354	64.0
3 or more	60	10.8
History of breast feeding=549 (4 who have not borne children have been excluded)
Yes	531	96.7
no	18	3.2
Average duration of breast feeding in months n=549
Less than 3	64	11.6
3-6	269	48.8
6-9	169	30.8
9-12	47	8.6
History of abortion n=721
Yes	104	14.4
no	617	85.6
History of smoking
Yes	04	0.5
no	717	99.4
Yes	11	1.5
no	710	98.5
History of oral contraceptive use
Yes	301	41.7
no	420	58.2
History of HRT
Yes	48	6.6
no	673	93.3
Age at menopause in years
Menopause not reached	501	69.5
40-45	40	5.5
40	172	23.8
51-55	08	1.1
Red meat consumption per week
Nil	452	62.6
1	72	10.0
2	169	23.4
3	21	2.9
More than 3	7	1.0
Physical exercise for 30 mints per week
No exercise	110	15.2
Occasionally	195	27.0
Less than 3 times	309	42.8
3-5 times	58	8.0
5 times or more	49	6.8
History of ovarian cancer in the family
Yes	07	1.0
no	714	99.0
History of ovarian removal in self
Yes	04	0.5
no	717	99.4
Body mass Index
Overweight (23-25 kg/m2)	321	44.5
Obese(more than 25)	274	38.0
BMI less than 23	126	17.5
Ever had FNAC/biopsy done besides breast cancer
Yes	17	2.3
no	704	97.6

19(2.6%) of the women had themselves undergone treatment for breast cancer on enquiring about the recent concerns about breast, pain was complained of by 47(6.5%) followed by discharge 39(5.4%) and lump 28(3.8%).21(2.9%) also complained of itching and redness in the breast. Only 32(4.4%) had ever examined their breasts. None had gone for a clinical breast examination as a screening method and only five (0.7%) had gone for a screening mammogram from their side. Main perceived reason for cancer of the breast cited by women was diet (adulteration/pesticides) 487(67.5%) followed by family history of breast cancer by 459(63.7%).Lump was a symptom about which 558(77.4%) of the women were aware .Least (29, 4%) number of women were aware regarding changes in the nipple as a sign of breast cancer.(Table 2)

Table2: Practices of the women regarding breast cancer screening N=721

Ever self-examined the breast	n	%
Yes	32	4.4
no	689	95.6
Ever gone for clinical breast exam for  screening by self
Yes	0	0
no	721	100
Ever had a screening mammogram done  by self
yes	05	0.7
no	716	99.3

Discussion

In the present study an attempt was made to study the high risk factors for breast cancer amongst working women from Delhi. Early menarche is a known risk factor for breast cancer. It was observed that 12.2% of the women had achieved menarche before reaching 12 years of age. In another study done in women from North India, Puri etal reported early menarche in 17.8% of the subjects [5].Estimates of the pooled analysis of the result of 21 studies shows that for each additional year at menarche is postponed, premenopausal and post menopausal breast cancer risk decreases by 9% and 4% respectively [6].Median age of menarche worldwide is 14 years with a range of 11 to 18 years and reported average late age of onset in Asian population as compared to west [6]. Younger the age at which childbearing begins lesser is the risk of breast cancer. In the current study 4.3% had first child birth after 30 years of age and 0.7% had never borne a child. This is low as compared to Chandigarh study in which 30.2% of the women had their first child after 30 years of age [5].

In the present study 14.4% of the women gave history of induced abortion whereas Puri et al reported it in 25.3% of the participants from Chandigarh [5].

Smoking was reported by 0.55percent of the participants in the present study. Pur iet al reported it in 10.2% of its participants from Chandigarh [5]. According to Kalra, 8.9% of the urban women smoke/use tobacco [7]. In India overall less than 20% women smoke. Even though the percentage prevalence of women smoking in India isn't that high, the number is huge. Indian women are among the worst in the world when it comes to smoking. According to the latest Tobacco Atlas, the country ranks third in the top 20 female smoking populations across the globe [8]. Alcohol intake was present in 1.5% of the women and for India the figure stands at less than 2% and officially Indians are still amongst the lowest consumers of alcohol [9]. Oral contraceptives were used by 41.7% of the women in present study. Puri reported its use in 17.7% of the participants [5]. This difference could be due to the fact that present study was done only in office going women and they might have a greater need for birth control.

Regular physical activity is associated with protective effect against breast cancer. In our study 42.2% of the women did not exercise regularly as compared to 29.7% observed by Purietal. Overall prevalence of sedentary behaviour was 59.3% as reported by Kalra et al which is higher than what has been observed in the current study [7]. Increased Body Mass Index shows an association with the breast cancer .In India, according to National Family Health Survey(NFHS) the percentage of ever-married women aged 15-49 years who are overweight or obese increased from 11% in NFHS- 2 to 15% in NFHS-3 [10]. In the present study, 44.5% of the women were overweight and 38% obese and 42.2% did not exercise regularly. A cross sectional survey conducted in 6-12 urban streets of 5 cities of India , overall prevalence of obesity in women was 7.8% and overweight 35%.It has also been reported that Delhiites have the highest general body fat as assessed by BMI and Grand mean thickness as well as fat percentage [11]. The percentage of women who are overweight or obese is highest in Punjab (30%), followed by Kerala (28%) and Delhi (26%), all of which are relatively richer states [7]. In the present study, 4.4% women had ever performed a Breast self exam. In another study from Delhi by Bari etal 11% women were aware and only 2 had examined themselves[12].In a study from south India by Sharma et al again a comparable figure of 4.4% were aware and performed BSE[11]. In another study among school teachers of Delhi only 36% had heard the term breast self examination and when it came to practice none did it[12]. In another study from OPD patients from a hospital of Mumbai Ahuja et al have reported that although 42% of the participants had heard the term only 15% practiced it[13].Clinical breast examination as a screening method was not availed by any participant both in the current study as well as one by Sharma et al. Bari et al reported from Delhi that only 5 subjects had done CBE only after experiencing pain. Khokhar from Delhi reveals that none of the schoolteachers ever went for a clinical breast exam or screening mammogram [14].(Table 3)

Table3: Distribution of the women according to knowledge of reasons of breast cancer and its signs

and symptoms (N=721)
Reason*	n	%
Diet/pesticides in food/adulteration	487	67.5
Family history	459	63.7
Delayed marriage	146	20.2
Radiation exposure	127	17.6
Obesity	98	13.6
Not having breast fed	49	6.8
Wearing a bra	45	6.2
Milk collection in the breast	28	3.9
Trauma to the breast	17	2.35
Knowledge about signs and symptoms
Lump in the breast	558	77.4
Pain in the breast	214	29.6
Change in size and shape of the breast	187	25.9
Discharge from nipple	168	23.3
Changes in shape of nipple	29	4.0

The present study revealed that only 5 women had gone for a screening mammogram this is in agreement with the result of Bari et al in which only 6 women were aware that mammogram could detect breast cancer early. One can easily derive from these facts that very low percentage of women are aware of screening methods and even lower percentage actually practices them [12].

Knowledge about perceived reasons of breast cancer was also poor amongst women. Only 6.8% of the participants knew that not having breast fed the newborn is considered to be a high risk factor for breast cancer. In a study by Bari etal only 35% of the women mentioned some risk factors of breast cancer. Puri et al in her study mentioned late initiation of breast feeding as a high risk factor stated by 15.3% and not practicing breast feeding by 16.9%.Delayed marriage was cited as a risk factor by 20.2% in the present study as compared to 5.9% mentioned by Puri etal .Bari et al reported that 20% women associated trauma to breast with breast cancer which was seen in 2.35% of the participants from the current study also.17.6% of the women reported exposure to radiation to be associated with breast cancer this reason was also mentioned by Puri et al in 8.9% .In the study from Mumbai less than one third were aware of OCbs and radiation exposure as a cause of breast cancer[13].In the present study 63.7% cited family history as a reason, whereas 58% of the school teachers also cited the same. Less than one third of women from Mumbai study were aware of genetics as a basis of breast cancer [15].13.6% perceived obesity as a high risk factor of breast cancer which is comparable to 11.6% mentioned by schoolteachers from Delhi [14]. In the present study comparatively higher proportion i.e. 77.8% of the women were aware that a lump in the breast could be a symptom of breast cancer, 47.2% of the participants from Puribs study ,42% from Bari et albs study and 21.4% from Sharma et albs study were also aware of lump as a symptom of this disease [5,12,13].29.4% mentioned pain in the breast to be a symptom which was reported by Puri et al to be 41.2% and Bari et al to be 41%. Nipple discharge was stated as a symptom by 23.3% in this study which is similar to 28.7% reported by Puri et al [5].

Conclusion

Although breast cancer is the commonest form of cancer to affect women of metropolitan cities of India and every day more and more number of women are becoming its victim, the knowledge regarding high risk factors and screening modalities is poor and the practice of screening is nonexistent. There is a need to develop a multipronged strategy to create awareness about the disease and promote screening facilities.

Authorbs contribution

DBL conceived the study participated in study design and edited the manuscript.

Conflict of interest

The author has no conflict of interests to declare.

Acknowledgement

The author would like to acknowledge the support extended by the administrative heads in giving permission to conduct the above mentioned work in their offices. The author is thankful to all the women who participated in this study.

Funding

No external source of funding

References

[1]National Cancer Registry Programme: Consolidated report of the population based cancer registries 1990-1996. Indian Council of Medical Research, 2001, New Delhi.

[2].Saxena S, Rekhi B, Bansal A, et al. Clinico-morphological patterns of breast cancer including family history in a New Delhi hospital, India b a cross-sectional study. World J SurgOncol, 2005,3: 67.

[3]. Murthy NS, Agarwal UK, Chaudhry K, Saxena S. A study on time trends in incidence of breast cancer bIndian scenario. Eur J Cancer Care, 2007 ,16 :185-6[pubmed]

[4]Government Health India reworks obesity guidelines, BMI lowered,Submitted on Wed, 11/26/2008 - 18:10

[5]S. Puri, C. Mangat, V. Bhatia, M. Kalia, A. Sehgal, A.P. Kaur: Awareness Of Risk Factors And Aspects of Breast Cancer Among North Indian Women. The Internet Journal of Health. 2009 Volume 8 Number 2.

[6]Risk Factors for Breast Cancer in India: an INDOX Case-Control Study2010 Network,http://www.indox.org.uk/research/epidemiology/casecontrol/breastcancer

[7]Kalra S, Unnikrishnan A G. Obesity in India: The weight of the nation. J Med Nutr 2012; 1:37-41

[8]. Kounteya Sinha India third on global 'female smoking list', Aug 27, 2009, 08.39am , TNN

[9]More Indian women dependent on alcohol IANS Nov 30, 2012, 01.35PM IST

[10].http://www.nfhsindia.org/nfhs3.html. Accessed on 6 March, 2012.[pubmed]

[11]Hindustan Times Delhi, Punjab top woman obesity list ChetanChauhan, Hindustan Times, New Delhi, October 22, 2007,accessed 18th May 2013.

[12]Somdatta P, Baridalyne N . Awareness of breast cancer in women of an urban resettlement colony of Delhi.Indian J Cancer, 2005, 42:149[pubmed]

[13]. Pawan Kumar Sharma, EnakshiGanguly, DishaNagda and T Kamaraju Knowledge, attitude and preventive practices of South Indian women towards breast cancer The Health Agenda, 2013, 1, Issue 1.

[14]. Khokhar A. Level of Awareness Regarding Breast Cancer and its Screening amongst Indian Teachers Asian Pacific Journal of Cancer Prevention,2009 , 10: 247-250[pubmed]

[15]. Ahuja, N. Chakrabarti: To Determine The Level Of Knowledge Regarding Breast Cancer And To Increase Awareness About Breast Cancer Screening Practices Among A Group Of Women In A Tertiary Care Hospital In Mumbai, India. The Internet Journal of Public Health.2010, 1 Number 1. DOI: 10.5580/1b7c